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4/77 ~ • <br />MINED LAND RECLAMATION <br />LIMITED IMPACT A,W SPECIAL 10-DAY PERMIT APPLICATION C9ECKLIST <br />n i . <br />File No. ~7-7s1 Name lK ~r1;4- ~i/~ (u pate of Filing (Completeness) <br />ITEM COMPLETE ADEQUATE COMMENTS <br />Application Form <br />1. Name of operation <br /> <br />r <br />2. Name of applicant/operator i~ <br />3. Address 6 phone (local offices) ~~ <br />4. Address 6 phone (general offices) i~ <br />5. Person to contact <br />6. Surface owners <br />D ~0/1~ <br />7. :fineral owners h <br />8. Type of mine/substance ~ <br />9. General location ~ elevation <br />10. county / <br />11. Acreage /_ <br />12. Fee s~ '~'"' <br />13. Present land use <br />14. Proposed future use <br />15. Signature <br />Maps and Exhibits <br />1. Exhibit A - Legal description <br />~ / <br />2. Exhibit S - ;fining plan <br />3. Exhibit C - Map <br />4. Exhibit D - Wildlife, Water Resources, <br />Vegetation and Soils infor- <br />motion / <br />V/ <br />5. Exhibit E - Reclamation plan <br />